HomeMy WebLinkAboutDer June Yang App 610252 01 19 23 A
(g ENVIRONMENTAL HEALTH
Catawba County Government Center
catawba county 25 Government Drive I P.O. Box 389 I Newton, NC 28658
public health Phone: (828) 465-8270 I Fax: (828) 465-8276
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Email: EHA:Imin(Cnnv:bnCou"tytN(.gov
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Application for Tattooing Permit `, D rlso CI)Sa
Date of Application 01/17/2023
Tattoo Artist Information:
First Name Der June Last Name Yang MI
Mailing Address: 1630 Tate Blvd SE
City Hickory State Zip 28602
Telephone Number:(828) 999-0199 E,mail:Juneyaj@gmail.com
Tattoo Establishment Information:
Name of Establishment:Arched & Polished
Street Address: 1630 TATE BLVD SE
city Hickory state NC zip 28602
Business Hours: M-F 10am-6pm
Number of Tattoo Artists in Establishment 2 Anticipated Dote to Begin Tattooing: Renewal
Tattoo Artist Signature: / /4__
instructions
Purpose: To allow tattoo artists to apply for tattooing permits a s required in General Statute 1 30A-283 and ISA NCAC I 8A.3202. A
separate application must be completed for each permit.
Preparation: Each tattoo artist must complete and sign a separate application for each location where he or she will engage in tattooing
within the State of North Carolina. The completed application must include the full name, mailing address and
signature of the tattoo artist, the name and street address of the tattoo establishment,and the anticipated date of
commencing operation.
Submission: The completed application must be submitted to the focal health department in the county where the tattoo establishment is
located at least 30 days before commencement of operation. The local health department may require payment of fees or
additional information upon submission of the application.
Disposition: This form may be destroyed in accordance with Standard 7 of the Records Disposition Schedule.Published by the N.C.
Division of Archives and History.
DER 4015(Revised l 1/00)
Environmental Health Service Section(Review 11/03)
4'A CATAWBA COUNTY
h� G 100A SOUTHWEST BLVD
NEWTON,NORTH CAROLINA 28658 RECEIPT
jci) �,�, PHONE: 828.465.8399
Thursday,January 19,2023
/8 4 2 sM www.catawbacountync.gov
PAYOR: Arched&Polished
Arched&Polished(Yang,Der(June))
PAYMENTS
TRANSACTION NUMBER: TRC-55814087-19-01-2023
PAYMENT DATE: 01/19/2023
PAYMENT TYPE: Credit Card
300035964
INVOICE NUMBER ACCOUNT FEE NAME FEE AMOUNT
01-23-417074 110-580200-663000 Tattoo Artist Fee $225.00
TOTAL PAYMENTS: $225.00
FLI-11-2018-108384
CASE TYPE: Food&Lodging Institutions WORK CLASS: 61 -Tattoo Artists
SITE ADDRESS: 1630 TATE BLVD SE,HICKORY NC 28602
Applicant ARCHED&POLISHED, 1630 TATE BLVD SE,HICKORY NC 28602
B:8285144204
**NO PEOPLESOFT ACCOUNT ASSIGNED**
receipt 01/19/2023 15:12 Page 1 of 1